Article Prevalence and Determinants of Vaccine Hesitancy and Vaccines Recommendation Discrepancies among General Practitioners in French-Speaking Parts of Belgium Cathy Gobert 1, Pascal Semaille 2, Thierry Van der Schueren 3 , Pierre Verger 4 and Nicolas Dauby 1,5,6,* 1 Department of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), 1000 Bruxelles, Belgium; [email protected] 2 Department of General Medicine, Université Libre de Bruxelles (ULB), 1070 Bruxelles, Belgium; [email protected] 3 Scientific Society of General Practice, 1060 Bruxelles, Belgium; [email protected] 4 Southeastern Health Regional Observatory (ORS PACA), 13005 Marseille, France; [email protected] 5 School of Public Health, Université Libre de Bruxelles (ULB), 1070 Bruxelles, Belgium 6 Institute for Medical Immunology, Université Libre de Bruxelles (ULB), 1070 Bruxelles, Belgium * Correspondence: [email protected] Abstract: General practitioners (GPs) play a critical role in patient acceptance of vaccination. Vaccine hesitancy (VH) is a growing phenomenon in the general population but also affects GPs. Few data exist on VH among GPs. The objectives of this analysis of a population of GPs in the Belgian Wallonia-Brussels Federation (WBF) were to: (1) determine the prevalence and the features of VH, (2) identify the correlates, and (3) estimate the discrepancy in vaccination’s behaviors between the GPs’ children and the recommendations made to their patients. An online survey was carried out Citation: Gobert, C.; Semaille, P.; Van among the population of general practitioners practicing in the WBF between 7 January and 18 der Schueren, T.; Verger, P.; Dauby, N. March 2020. A hierarchical cluster analysis was carried out based on various dimensions of vaccine Prevalence and Determinants of hesitancy: perception of the risks and the usefulness of vaccines as well as vaccine recommendations Vaccine Hesitancy and Vaccines for their patients. A total of 251 GPs answered the survey. The average percentage of moderate Recommendation Discrepancies among General Practitioners in to high vaccine hesitancy was 50.6%. Three factors were independently associated with increased French-Speaking Parts of Belgium. risk of vaccine hesitancy: an age <50 years old, having no children, and having no contact with Vaccines 2021, 9, 771. https:// selected vaccine-preventable disease (measles, complicated influenza, chronic hepatitis B (HBV), doi.org/10.3390/vaccines9070771 bacterial meningitis, or cervical cancer) in the past 5 years. VH was associated with controversies on vaccines’ safety. GPs who had vaccinated their children against six diseases (MMR, meningococcus C Academic Editor: Brian D. Poole (MenC), HBV, and HPV) tended not to recommend the same vaccines to their patients. Among GPs with all children vaccinated against HBV, only 37.5% recommended catch-up HBV immunization to Received: 9 April 2021 their patients. In this small cohort of GP, moderate to high VH was associated with controversies Accepted: 6 July 2021 on vaccines’ safety and with specific personal characteristics (age <50, no children, and no recent Published: 10 July 2021 experience with a serious VPD). As previously reported, GPs have different vaccine prescription attitude toward their patients and children. These findings should be confirmed in larger cohorts. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in Keywords: vaccine hesitancy; general practice; health-care workers; vaccination published maps and institutional affil- iations. 1. Introduction Vaccination is a simple and effective means of protecting against certain potentially Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. fatal diseases. Vaccination provides both individual and community protection for certain This article is an open access article vaccine-preventable diseases and has also broad societal impact that includes increased distributed under the terms and productivity, positive fiscal impact, and decreased antibiotic consumption [1]. In order conditions of the Creative Commons to avoid the resurgence of vaccine-preventable diseases (VPD), it is necessary to keep a Attribution (CC BY) license (https:// sufficiently high vaccination coverage. creativecommons.org/licenses/by/ In Belgium, only the polio vaccine is currently compulsory [2]. Vaccination coverage 4.0/). in the Wallonia-Brussels Federation (WBF), the two French-speaking regions of Belgium, Vaccines 2021, 9, 771. https://doi.org/10.3390/vaccines9070771 https://www.mdpi.com/journal/vaccines Vaccines 2021, 9, 771 2 of 13 particularly for measles–mumps–rubella (MMR) and for human papillomavirus (HPV) vaccination, is still far from sufficient. For example, vaccine coverage for the second doses of MMR among adolescents was 75% [3]. In the last years, measles outbreaks have been reported both in Brussels and Wallonia regions [4,5]. Vaccine hesitancy (VH) is considered an important cause of under-vaccination [6]. The concept of a matrix of determinants of hesitation, influencing the decision and/or the vaccination methods, has also been proposed in order to group different factors into three impact categories. These categories are contextual, individual, and group, as well as those specific to the vaccine and/or vaccination [7]. In 2016, VH was reported in more than 90% of countries in the world, regardless of socio-economic level [8]. In a 2016 study of 67 countries, Europe had the lowest level of confidence in vaccine safety [9]. Different factors contribute to increased VH: potential side effects, belief that the vaccine could cause the disease it was meant to prevent, doubt about the safety of adjuvants, and overloading the immune system [8]. VH is not limited to patients but also affects healthcare professionals (HCP) [10]. Several causes of VH among HCP have been highlighted: a lack of confidence in the health authorities, the fact of not feeling comfortable transmitting quality information to patients, the fear of serious side effects and doubts regarding the safety of adjuvants and also the efficacy of some vaccines [11]. General practitioners (GPs) play a key role in the promotion and acceptance of vacci- nation in Belgium as well as in many other countries. Various studies have shown that (1) GPs remain one of the most reliable advisers in the eyes of patients and (2) patients tend to be more reassured when information comes from their doctor [12,13]. In 2014, Verger et al. reported a method to describe and estimate the extent of vaccine hesitancy among GPs. Using a survey that included different dimensions of vaccine hesi- tancy (self-reported vaccine recommendations, perceptions of vaccine risks and usefulness), they were able to identify three clusters of GP with different grade of VH. GP with the higher degree of VH were less frequently vaccinated and reported more frequent occasional practice of alternative medicine but also less experience with VPD [11]. Interestingly, recent studies have shown a discrepancy in immunization recommen- dation in a high proportion of GPs toward members of their family, themselves, and their patients [14,15]. There is only a limited amount of data on VH among HCP [13,14,16,17]. In French- speaking parts of Belgium, at present, there is no documented study on this subject. The objectives of the present study were to (1) estimate VH prevalence in a sample of GPs practicing in the Wallonia-Brussels Federation, (2) identify the factors influencing VH among GPs, and (3) highlight the existence or not of a discrepancy between the vaccination of doctors and their children compared to that of their patients. 2. Materials and Methods 2.1. Study Design An online survey aimed at GPs practicing in the Wallonia-Brussels Federation was conducted between 7 January 2020 and 18 March 2020. An online questionnaire was distributed by email to GPs thanks to the collaboration of the Scientific Society of General Practice (SSGP) and the Belgian group of general practitioners (GBO). In addition, sev- eral associations of GPs in the Wallonia-Brussels Federation were contacted in order to disseminate the survey to their members by email. 2.2. Data Collection Each GP who agreed to participate in the study answered a questionnaire that included 24 questions (Supplementary materials File S1). This questionnaire was created and standardized by Verger and colleagues [11] For this work, the questionnaire was adapted to match the specificities of the WBF vaccination program (Supplementary materials Table S2). Participants were asked about their personal and professional vaccination Vaccines 2021, 9, 771 3 of 13 practices. They were asked about their views on vaccination and potential barriers to vaccination. The participants gave their opinion on various possible actions pertaining to vaccination. To answer the questions, 4- or 5-point Likert scales were used [18]. The data collection was anonymous. Data were collected using the open-source LimeSurvey software (LimeSurvey GmbH, Hambourg, Germany) hosted on the servers of the Université Libre de Bruxelles (ULB). 2.3. Immunization Discrepancies between Family and Patients of General Practitioners Among GPs with ≥1 child, immunization recommendations of four vaccines (HPV, MMR, meningococcus C (MenC), and Hepatitis B (HBV)) toward their patients were compared with the immunization practice with their family members. 2.4. Statistical Analysis In order to classify population sample according to VH, a previously